Abstract

Exercise training has proven to be beneficial in the prevention of disease. In addition, exercise can improve the pathogenesis and symptoms associated with a variety of chronic disease states and can attenuate drug-induced adverse effects. Exercise is a drug-free polypill. Because the benefits of exercise are clear and profound, Exercise is Medicine, a joint initiative between the American Medical Association and American College of Sports Medicine, was launched in 2007 to call on all health care providers to counsel patients and prescribe exercise in the prevention and treatment of chronic disease states. Pharmacists play an increasing role in direct patient care and are the most accessible health care providers in the community. Thus, pharmacists should be knowledgeable in counseling patients on the frequency, intensity, time, and type of exercise that is appropriate for various conditions and disease states. The aim of the present study was to determine the prevalence of didactic course offerings in United States pharmacy school curricula regarding training in exercise prescription. School websites were accessed for information regarding course offerings in PharmD programs. No United States pharmacy schools offered courses that were dedicted to the role of exercise in disease prevention or exercise prescription in disease management. Ninety percent of pharmacy schools did not offer courses with the keywords “exercise,” “fitness, or ”physical activity“ in the title or description. The data suggest that student pharmacists are not adequately trained to counsel patients on the benefits of exercise or exercise prescription.

curriculum

education

Exercise is Medicine

exercise prescription

pharmacy

exercise prescription refers to the development of a specific exercise regimen designed for a specific purpose. Exercise has proven to be a drug-free polypill, exerting numerous physiological and psychological health benefits (5). Chronic physical activity is associated with reduced rates of cardiovascular disease, hypertension, metabolic syndrome, diabetes, certain types of cancer, osteoporosis, depression, all-cause mortality, and more (5, 9, 15). In addition, exercise training has shown to be beneficial in attenuating a number of drug-induced adverse effects and toxicities (1, 2, 4, 6, 10, 14). Despite the myriad of health benefits, it is estimated that ∼33% of adults worldwide are physically inactive (7). Evidence suggests that up to 5.7 million deaths from noncommunicable diseases could have been prevented globally if inactive individuals were sufficiently active (8). The economic burden of inactivity is costly. For example, in 2007, the annual direct and indirect health care costs were estimated to be $155–419/individual in Canada and the United States (U.S.) (8). For these reasons, Exercise is Medicine, a joint global initiative between the American Medical Association and American College of Sports Medicine, was launched in 2007 to call on all health care providers to counsel patients and prescribe exercise in the prevention and treatment of chronic disease states (12, 13).

Pharmacists play an increasing role in direct patient care and are the most accessible health care providers in the community. Pharmacists are expanding their role in the community to include immunizations, point of care testing for diabetes and cholesterol, blood pressure screenings, medication therapy management, and additional nondispensing services. Furthermore, the Center for the Advancement of Pharmaceutical Education recommends colleges and schools of pharmacy include the development of student skills in the area of overall public health in their educational outcomes. Therefore, pharmacists should be knowledgeable in counseling patients on the frequency, intensity, type, and time of exercise that is appropriate for the goal of patients with various conditions and disease states. One generalized exercise regimen is not sufficient to meet the goals of every patient. For example, the physical activity sufficient to decrease risk of developing chronic diseases and delay mortality (30 min for 5 days/wk at moderate intensity recommended by the Centers for Disease Control and Prevention and American College of Sports Medicine), is not sufficient to prevent or reverse weight gain in most subjects. Such knowledge seems pertinent given that 73% of men and 63% of women in the U.S. are overweight or obese; 80% of Americans will be overwieght by 2040, with a health care cost of $1 trillion (16). Diet and exercise are the first lines of treatment. Furthermore, the type or mode of exercise may need to be modified depending on varying physical limitations. Being the most accessible health care provider, pharmacists have a prime opportunity to counsel patients on exercise prescription suitable to meet select goals while optimizing adherence, but require knowledge to do so. Therefore, the aim of the present study was to determine the prevalence of exercise prescription-related didactic course offerings in U.S. pharmacy school curricula to help determine the preparedness of pharmacists to take on the role as a health care provider to counsel patients on exercise prescription.

METHODS

Websites of all 135 accredited U.S. pharmacy schools were accessed in 2014–2015 to identify courses with titles or descriptions containing keywords that may indicate content pertaining to exercise prescription. Schools that did not provide titles and/or descriptions for all required and elective courses on their website were not included in the analysis. Websites of 118 pharmacy schools provided complete listings of course titles and descriptions and thus were included in the study. Keywords included the following: exercise, physical activity, fitness, disease prevention, preventative care, health, wellness, nonpharmacological treatments, self care, diabetes management, and lifestyle. When a course was identified with one of the keywords in the title, the following information was collected: public or private institution, course credit hours, title and description of course, and whether it was an elective or required course. Data from all schools were initially collected independently by two individuals. Once the data was compared and combined, 20 schools were spot checked at random for accuracy by a third individual.

RESULTS

There are 135 accredited pharmacy schools in the U.S., but data from only 118 school websites were collected; 17 schools did not provide titles and/or descriptions for all required and elective courses and thus were not included in the analysis. Of the 118 schools, no courses were identified with the term “exercise prescription” in the title or description. Two schools of pharmacy offered a course with the terms “exercise,” “fitness,” or “physical activity” in the title (Exercise Pharmacology & Toxicology; Exercise, Diet, & Disease). Each were four-unit elective courses. Eleven additional courses, from ten schools, were identified with the terms “exercise,” “fitness,” or “physical activity” in the description. Seven were elective courses and four courses were required courses in the pharmacy curriculum. Eight of the courses were ≤2 credit hours. Fourteen courses, from thirteen schools, were identified with other keywords (e.g., “disease prevention,” “preventative care,” and “lifestyle modifications”) in the title or description, implying exercise as a likely course topic. However, the keywords “exercise,“fitness,” or “physical activity” were not used in the course title or description. Half of the courses were offered as elective and half as required. Eight of these courses were ≤2 credit hours. See Fig. 1 for a summary of the data. Of all the courses that were identified and mentioned above, none dedicated the course to solely exercise. All courses consisted of combined content, including diet and other health and lifestyle modifications. By the course descriptions, it could not be determined how much time was spent discussing the topic of exercise nor could it be determined how much time, if any, was spent discussing the topic of exercise prescription rather than the benefits of exercise. Of the 25 pharmacy schools that offered these courses, 13 pharmacy schools were private and 12 pharmacy schools were public institutions.

Summary of exercise-related courses offered by United States pharmacy schools (118 of 135 accredited schools included in complete analysis). Thirteen courses were identified that included the keywords “exercise,” “fitness,” or “physical activity” in the course title or description. Fourteen additional courses were identified with other keywords in the title or description implying exercise as a possible topic. The majority of the courses identified were elective courses of ≤2 credit hours.

DISCUSSION

Exercise has proven to be beneficial in the prevention and treatment of most chronic noncommunicable disease states and without the adverse side effects associated with therapeutic drugs. Exercise is Medicine was initiated to call on all health care professionals to counsel patients and prescribe exercise in an effort to reduce morbidity and mortality associated with chronic disease. Pharmacists are the most accessible health care providers in the community and so it makes sense to enlist them as a part of the Exercise is Medicine initiative. However, according to the data in this study, it appears that most student pharmacists are not adequately trained to counsel patients on the frequency, intensity, type, or time of exercise that patients should be engaging to meet specific goals based on disease conditions or physical limitations. It is likely that student pharmacists learn relatively little about the specific benefits of exercise and even less about exercise prescription.

The data revealed that no schools of pharmacy offer didactic courses with the term “exercise prescription” in the course title or description. From 118 schools in which data was collected, only 12 schools offered courses with the terms “exercise,” “fitness,” or “physical activity” in the title or description. Another 13 schools offered courses that potentially discussed the topics of exercise in health and disease but did not specifically include these keywords. Since most of these courses were elective, ≤2 credit hours, and included multiple course topics, the data suggests that student exposure to exercise-related curricula is minimal. For example, in a 2-credit hour elective course offered at our pharmacy school titled “Therapeutic Lifestyle Changes,” only half of a 50-min lecture is dedicated to exercise. The exercise-related topics included a brief list of general benefits, barriers for lack of exercise and suggestions to overcome those barriers, the general minimum guideline recommended by the American Heart Association (150 min/wk at moderate intensity or 75 min/wk at vigorous intensity), and exercise zones based on maximum heart rate. Syllabi and lectures were not accessible online for the remainder of the courses identified in this study; therefore, it could not be determined the time dedicated to exercise-related topics in each course nor the exercise-related topics actually discussed (whether it was benefits of exercise, exercise prescription, etc.). Although student pharmacists are not exposed to much didactic coursework pertaining to exercise prescription, it is possible that they are exposed to exercise prescription during clinical rotations. However, this was not assessed in this study.

In the primary literature, Persky et al. (11) described an exercise prescription course that was developed and offered to pharmacy students in 2007 and 2008; however, this course could not be found on the school website. This suggests that it may no longer be offered. It was described as a 3-credit hour PharmD elective course with the goal to introduce basic concepts and selected therapeutic applications of exercise testing and prescription. The intent was not for pharmacy students to become exercise specialists (11). Topics included body composition, barriers to exercising, aerobic training principles, resistance training principles, risk assessment, exercise-drug interactions, and exercise prescription in special populations and various disease states. The class size and response rate to the student survey were limitations in assessing the effectivenes and quality of the course. However, students who completed the survey rated the course as 4.8 on a Likert scale, with 5 being the highest rating, and felt that the course improved their confidence in providing exercise recommendations.

A recent study (3) has been published indicating that the majority of U.S. medical schools also did not offer courses focusing on the topic of physical activity or exercise prescription. Nearly 52% of medical schools in which curricular information was accessible on their website did not offer such a course. Of the schools who did offer a course, it was most often an elective course. Eighty-two percent of medical schools did not require their students to take a single course relating to physical activity or exercise prescription (3). Thus, it seemingly appears that most medical students nor pharmacy students are obtaining the training needed to adequately counsel patients on exercise.

Since pharmacists are accesible in the community and are taking on more of a nondispensing role, it is vital that they educate patients on exercise. The pharmacist has many opportunities to discuss exercise with the patient as if it is another medication for them to take. Patients with chronic disease states, such as diabetes, can benefit substantially from exercise. Exercise not only helps diabetic patients with weight loss but also increases glucose uptake by skeletal muscle via insulin-dependent and insulin-independent mechanisms, helping to lower blood glucose levels. Thus, exercise can alter the required amount of insulin that is important for the patient self-administering insulin to understand since too much or too little has medical consequences. For some, it may be possible to discontinue medication therapy for their diabetes.

It is not expected that pharmacists should become experts in exercise physiology and exercise prescription; however, some basic knowledge on the following topics may prove advantageous to improve the effectiveness of patient counseling on exercise (aerobic and resistance training): benefits of exercise training on the physiology of each organ system and associated chronic disease states, general principles and components of an exercise prescription (frequency, intensity, type, and time of exercise), methods to monitor exercise intensity, contraindications to exercise, special considerations for various populations or disease states, medications that interfere with exercise response, and behavioral theories and strategies for promoting exercise adherence. Increased instruction on the topic of exercise prescription in the pharmacy curricula would fulfill the Center for the Advancement of Pharmaceutical Education recommendations of developing student skills in the area of public health as well as increase the number of health care providers partaking in the Exercise is Medicine initiative.

It is appreciated that the required pharmacy school curricula is already near its maximum capacity, which imparts an already full schedule for doctoral level pharmacy students. Instead of offering a required stand-alone course on exercise prescription, it may be recommended that pharmacy schools offer an elective course dedicated to the topic of exercise prescription and/or incorporate select topics of exercise prescription into already existing courses. For example, most pharmacy school curricula consist of individual courses on the pharmacotherapy of disease states for each organ system. Exercise prescription for the relevant populations could be incorporated into each pharmacotherapy course.

In conclusion, no pharmacy schools offered a course dedicated to exercise or exercise prescription in health and disease. There are 135 accredited pharmacy schools in the U.S.; however, only 118 included complete course listings and, therefore, were included in this study. Of the 118 websites and course listings analyzed, 90% of them did not offer courses containing the keywords “exercise,” “fitness,” or :physical activity” in their title or descriptions. U.S. pharmacy school curricula provides very little, if any, education on exercise prescription despite the fact that exercise is medicine. It is likely that the courses offered do not provide the student pharmacist with sufficient knowledge about exercise prescription to adequately counsel patients with varying disease conditions or physical limitations. Pharmacists appear to be an untapped resource in the community to not only educate patients on the benefits of exercise but to also counsel on the frequency, intensity, type, and time of exercise that is appropriate for varying patient populations.

DISCLOSURES

No conflicts of interest, financial or otherwise, are declared by the author(s).

; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet380: 219–229, 2012.